Provider Demographics
NPI:1790484624
Name:THEISS, NICOLE GRACE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:GRACE
Last Name:THEISS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 PINE ST
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-6236
Mailing Address - Country:US
Mailing Address - Phone:914-348-3040
Mailing Address - Fax:
Practice Address - Street 1:66 PINE ST
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-6236
Practice Address - Country:US
Practice Address - Phone:914-348-3040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical